interventional management of crps · interventional management of crps edward babigumira m.d....

INTERVENTIONAL

MANAGEMENT OF CRPS

Edward Babigumira M.D. FAAPMR.

Diplomate ABPMR.

Board Certified Pain Medicine

Disclosure

� No disclosures

Goals and Objectives

� Discuss the role of interventional therapy

for CRPS.

� Evidence based medicine behind most of

these procedures.

� Techniques and potential complications of

these procedures.

Interventional Therapies for

CRPS

� Nerve Blocks and Intravenous Regional

Anesthesia (IVRA).

� Chemical and Surgical Sympathectomy.

� Implantable Spinal Medication Pumps.

� Spinal Cord and Peripheral nerve

Stimulation.

� Deep Brain Stimulation

Nerve Blocks

� Sympathetic nerve blocks are both diagnostic and therapeutic for CRPS with sympathetically maintained pain. (SMP).

� Pt’s with mechanical allodynia with burning pain, temperature and skin color skin changes are reasonable candidates for sympathetic blockade

� Role of sympathetic nervous system is poorly understood but presumed essential component of syndrome.

� Sympathetic blockade encouraged as early as possible to interrupt and reverse process.

Types of Sympathetic and

Nerve Blocks.

� Stellate Ganglion Block

� Lumbar Paravertebral Sympathetic

Ganglion Block

� Bier Block

Indications for Stellate

Ganglion Blocks� CRPS type 1 and 2

� Acute pain of Herpes Zoster.

� Post-herpetic neuralgia.

� Acute and chronic vasculopathies.

� Migraine, tension, cluster headaches

� Raynuad’s Disease and Buerger’s disease.

� Hyperhidrosis and frostbite.

� Phantom limb and stump pain, angina pectoris.

� Thoracic outlet syndrome and scapulohumeral periarthritis.

Stellate Ganglion Anatomy

� Cervical sympathetic chain contains 3 interconnected ganglia, superior, middle and inferior ganglia.

� 80% of pts the inferior ganglion is fused with the first thoracic ganglion to form the stellate ganglion (cervicothoracic ganglion).

� When the two are not fused, the first thoracic ganglion is labelled the stellate ganglion.

� It usually lies on or above the neck of the first rib

Sympathetic Ganglion

Anatomy

Stellate ganglion anatomical

landmarks.� Chassaignac’s Tubercle: The anterior tubercle of the transverse process

of the sixth cervical vertebra.

� Anterior

The structures anterior to the ganglion include the skin and subcutaneous tissue, the sternocleidomastoid and the carotid sheath. The dome of the lung lies anterior and inferior to the ganglion.Medial

The prevertebral fascia, vertebral body of C7, esophagus and thoracic duct lie medially. Posterior

Structures posterior to the ganglion include the longus colli muscle, anterior scalene muscle, vertebral artery, brachial plexus sheath and neck of the first rib.

C6 Anterior Approach

Technique� IV line started and standard resuscitative

equipment must be readily accessible.

� Pt placed in supine position with head lifted forward and tilted backwards to straighten the esophagus and move it away from the transverse processes.

� Cricoid cartilage palpated to discern the level of the C6 transverse process.

� The Chassaignac tubercle at C6 is identified approx 3cm cephalad to the sternoclavicular joint at the medial border of the sternocleidomastoid.

Technique

� The trachea and carotid pulse are palpated.

� The carotid artery is retracted away from the needle entry site.

� A 22g 4-5cm needle is advanced downward and perpendicular to the table until it touches bone and then withdrawn approx 2mm.

� Careful aspiration must be performed before injection.

� Initial test dose of 0.5-1ml is instilled to avoid seizure activity or LOC.

Technique

� Flouroscopy, CT, MRI, U/S or radiotracers may be used to confirm correct needle placement.

� 1-2ml of contrast instilled to visualize spread to r/o intravascular, intrathecal, epidural or intrapleural spread.

� Volumes of 5-20mls have been used, volumes greater than 20ml’s result in a higher incidence of recurrent laryngeal nerve block.Opioids or clonidine have been used alone or in combination with local anesthetics.

Other techniques

� C7 anterior approach:

� Posterior thoracic approach.

Effects of the block

� Ptosis, Miosis, enopthalmos and anihidrosis.

� Increased blood flow due to vasodilation.

� Left stellate block can increase heart rate and blood pressure. The QTc interval and QT dispersion interval is decreased.

� Right stellate block may result in RR interval changes.

� May modulate the immune system.

� May increase retinal venous blood velocity and decrease intraocular pressure.

Side effects and complications

� Complication are rare with incidence on 0.17%.

� Ptosis, miosis, nasal congestion, facial warmth.

� Recurrent laryngeal nerve block results in hoarseness, feeling of a lump in the throat or shortness of breath.

� IV injection may result in LOC, apnea, hypotension, seizures.Transient locked in syndrome.

� Intrathecal, epidural, subdural injection may require respiratory assistance.

� Pneumothorax, hematoma, intercostal neuralgia.

Sympathetic Block Outcomes

for CRPS� A good response includes a temp rise which

appears to predict better pain response.

� Repeat blocks may be considered for short term benefit.

� There is no convincing evidence to support an extended series of blocks.

� Repeated blocks may lessen in effectiveness over time.

� Continuous spinal infusion catheters may be considered for pt’s with markedly decreased ROM, poor pain control and intolerance to touch.

Lumbar Paravertebral

Sympathetic Block� Anatomy: The lumbar sympathetic chain lies

along the anterolateral surface of the lumbar

vertebral bodies.

� It contains pre and post ganglionic fibers to the

pelvis and lower extremities.

� Most ganglia are located at the anterolateral

surface of the lower third of the 2nd lumbar

vertebra hence the best site for needle placement.

Indications

� Determine the degree of SMP in a pt with CRPS.

� Both a prognostic and therapeutic block.

� Improvement of blood flow in pt’s with vascular

insufficiency of the lower extremities.

� Management of neuralgic pain after traumatic

peripheral nerve injuries or amputation.

Technique

� Flouroscopic guided technique is preferable.

� Pt is placed in a prone position.

� Site of insertion is 2-3cm below and medial to the 12th rib opposite the vertebral body of L3.

� A 5-7’ spinal needle is inserted 8-10cm from midline at a 30-45 deg angle lateral to the spinous process to reach the anterolaterla aspect of the lumbar vertebra.

� 2-3cc of contrast are instilled to show linear spread anterior to the psoas muscle.

� 15-20 cc of local anesthetic are then instilled.

Complications

� Bleeding from puncture of the lumbar vessels or aorta.

� Hematuria, infection.

� Orthostatic hypotension.

� Perforation of abdominal viscera.

� Transient backache and stiffness

� Epidural, subacrachnoid and lumbar plexus blockade, segmental nerve injury.

� 5-40% incidence of post block neuralgia.

Lumbar Neurolytic

Sympathectomy� 2-4ml of 6% phenol can be used as a neurolytic

agent. The pt is kept on the side for 15-30 minutes

to prevent lateral spread.

� Radiofrequency sympatholysis has been described

with a heat lesion at 80deg for 90 seconds.

� Rocco et al showed that 20 pt’s who had RF

sympathectomy, 5 pts continued to have relief

5mths to 3 years after the procedure while 15 had

temporary or no relief at all.

Surgical Sympathectomy

Regardless of the technique regeneration of the sympathetic chain typically occurs.

� Overall impression of the literature suggests potential of even worse pain in unsuccessful cases.

� In one report 20% of pt’s developed sympathectomy neuralgia or “sympathalgia” or a new CRPS.

� A case series of thoracoscopic thoracic sympathectomies for upper ext pain noted a lower success rate for CRPS than other diagnoses with 50% recurrence

Monitoring adequacy of the

block� Horner’s syndrome.

� Unilateral nasal stuffiness. (Guttman’s sign)

� Hyperemia of the tympanic membrane and facial warmth.

� Thermography, plethysmography, laser doppler flowmetry. (adrenergic fiber activity.)

� Sudomotor (cholinergic fiber activity). Sweat test, sympathogalvanic response.

� Skin temperature with adhesive thermocouple probes.

IVRA or Bier Block

� Used as diagnostic and therapeutic tool for CRPS.

� The literature on the role of Bier blocks in CRPS

remains murky with some studies showing benefit,

others showing none, and no consistency on the

medications used.

� Minimal evidence to support intravenous regional

anesthesia using bretylium, guanethidine, steroids,

clonidine or NSAID’s added to local anesthetic.

Bier Block

� First described by a German surgeon August K.G.

Bier in 1908.

� He describes complete motor paralysis and

complete anesthesia of an extremity after

intravenous injection of prilocaine in an

exanguinated limb.

� Now commonly used for minor hand and wrist

surgeries using lidocaine because of it’s simplcity

and reliability.

Technique

� A torniquet(double cuff) is placed on the proximal arm of the extremity to be blocked.

� A small IV catheter is introduced into the dorsum of the hand.

� The cuff is inflated to 100mm Hg above the systolic blood pressure or 300mm Hg.

� 12-15mls of lidocaine 2% is slowly instilled.

� Adjuvants like meperidine, clonidine are sometimes added to increase the analgesic effect.

Bier Block Technique

�

Complications

� Sytemic toxicity of the local anesthetic.

� Hematoma.

� Engorgement of the extremity.

� Subcutaneous hemmorhage.

Spinal cord and peripheral

nerve stimulation� SCS introduced as a tool

for CRPS in the 1960’s but overly enthusiastic and indiscriminate use led to a waning period.

� Pt’s who respond to sympathetic blocks may do better with SCS.

� 3 systems available on market, Boston Scientific, ANS and Medtronic

SCS and CRPS

� Kemler et al. randomized severely disabled, treatment refractory pt’s with CRPS to one of 2 conditions. SCS +PT or PT alone. Pt’s were permanently implanted only if a SCS trial was successful in 24 of 36 cases in SCS +PT group.

� Pt’s in the SCS +PT group experienced significant reduction in pain intensity compared to the PT only group.

� After 2 years, the same cohort of pt’s with SCS still reported pain relief and improved health quality of life, however there was no difference in functional outcome.

SCS and CRPS

� Durability of the response beyond 2 years remains an issue given that a recent review of SCS shows a diminishing effect over time for many pt’s.

� There is still a dilemma on when to use SCS in pts with CRPS, the following moderate criteria have been proposed: No progress with PT/OT, psychologically stable, good understanding of the risk/benefit ratio, functional status sufficient to participate in exercise after procedure and a favorable response to a prior sympathetic block.

SCS lead placement

Implantable spinal medication

pumps� Very limited literature on the role of implantable

intrathecal pumps for management of CRPS primarily consisting of case reports.

� A viable consideration if pt fails with SCS or has coexisting types of pain or multiple pain sites.

� Morphine has been shown to help

� Baclofen may have a role with dystonia pt’s

� The role of Ziconotide, clonidine and other opioids remains unclear.

Deep Brain Stimulation

� Has the least evidence in the literature.

� Has been in use since the 1950’s.

� Electrodes are implanted in the somatosensory

thalamus and the periventricular gray region.

� As the most draconian procedure, it should be

reserved for the most severe and desperate cases.

� Must be weighed for potential risks relative to any

benefits.

Complications

� Apathy

� Hallucinations.

� Compulsive gambling.

� Hypersexuality.

� Cognitive dysfunction.

� Depression.

� Decline in executive

function.

THE END

� THAT’S ALL FOLKS, THANKS FOR

YOUR ATTENTION

References

� Essentials of pain medicine and regional

anesthesia. Benzon, Raja, Molloy.

� Interventional therapies in the management of

complex regional pain syndrome . David Nelson

and Brett Stacey, MD.

� Human Anatomy Atlas by McMinn, Hutchings.

� Images from NYSRO, McMinn and Benzon.

� SCS images from ANS